Optimizing the Patient Experience in Breast Imaging Facilities: AJR Expert Panel Narrative Review.

Breast imaging studies are complex examinations for patients and providers. Breast imaging providers and organizations invest significant resources in educating patients and referring providers to address variability in changing breast cancer screening recommendations, cultural biases, and socioeconomic barriers for patients. The breast imaging examination frequently involves multiple imaging modalities including interventional procedures, thus requiring multiple room types. Practices need to consider variables that affect workflow efficiency throughout the process of scheduling, examination performance, interpretation, and results delivery, as well as options in facilities design to create inviting yet functional environments for patients. Breast imaging appointments provide opportunity to capture individual breast cancer risk and to engage patients in health education and breast screening awareness. This AJR Expert Panel Narrative Review discusses ways in which breast imaging facilities can optimize patient experience throughout the complex process of a breast imaging examination, based on the authors' observations and opinions that include private and academic breast imaging experience.

Minimally Invasive Breast Procedures: Practical Tips and Tricks.

OBJECTIVE. The purpose of this article is to review the literature regarding image-guided breast procedures, including helpful tips and tricks to guide the practicing interventional breast radiologist. CONCLUSION. The successful diagnosis and treatment of breast cancer involves coordination of the multidisciplinary breast team. Optimal procedural skills for image-guided biopsy and preoperative lesion localization are paramount to the radiologists' success.

Dynamically decreased miR-671-5p expression is associated with oncogenic transformation and radiochemoresistance in breast cancer.

BACKGROUND: Understanding the molecular alterations associated with breast cancer (BC) progression may lead to more effective strategies for both prevention and management. The current model of BC progression suggests a linear, multistep process from normal epithelial to atypical ductal hyperplasia (ADH), to ductal carcinoma in situ (DCIS), and then invasive ductal carcinoma (IDC). Up to 20% ADH and 40% DCIS lesions progress to invasive BC if left untreated. Deciphering the molecular mechanisms during BC progression is therefore crucial to prevent over- or under-treatment. Our previous work demonstrated that miR-671-5p serves as a tumor suppressor by targeting Forkhead box protein M1 (FOXM1)-mediated epithelial-to-mesenchymal transition (EMT) in BC. Here, we aim to explore the role of miR-671-5p in the progression of BC oncogenic transformation and treatment. METHODS: The 21T series cell lines, which were originally derived from the same patient with metastatic BC, including normal epithelia (H16N2), ADH (21PT), primary DCIS (21NT), and cells derived from pleural effusion of lung metastasis (21MT), and human BC specimens were used. Microdissection, miRNA transfection, dual-luciferase, radio- and chemosensitivity, and host-cell reactivation (HCR) assays were performed. RESULTS: Expression of miR-671-5p displays a gradual dynamic decrease from ADH, to DCIS, and to IDC. Interestingly, the decreased expression of miR-671-5p detected in ADH coexisted with advanced lesions, such as DCIS and/or IDC (cADH), but not in simple ADH (sADH). Ectopic transfection of miR-671-5p significantly inhibited cell proliferation in 21NT (DCIS) and 21MT (IDC), but not in H16N2 (normal) and 21PT (ADH) cell lines. At the same time, the effect exhibited in time- and dose-dependent manner. Interestingly, miR-671-5p significantly suppressed invasion in 21PT, 21NT, and 21MT cell lines. Furthermore, miR-671-5p suppressed FOXM1-mediated EMT in all 21T cell lines. In addition, miR-671-5p sensitizes these cell lines to UV and chemotherapeutic exposure by reducing the DNA repair capability. CONCLUSIONS: miR-671-5p displays a dynamic decrease expression during the oncogenic transition of BC by suppressing FOXM1-mediated EMT and DNA repair. Therefore, miR-671-5p may serve as a novel biomarker for early BC detection as well as a therapeutic target for BC management.

Can Digital Breast Tomosynthesis Replace Full-Field Digital Mammography? A Multireader, Multicase Study of Wide-Angle Tomosynthesis.

OBJECTIVE. The purpose of this study was to test the hypothesis whether two-view wide-angle digital breast tomosynthesis (DBT) can replace full-field digital mammography (FFDM) for breast cancer detection. SUBJECTS AND METHODS. In a multireader multicase study, bilateral two-view FFDM and bilateral two-view wide-angle DBT images were independently viewed for breast cancer detection in two reading sessions separated by more than 1 month. From a pool of 764 patients undergoing screening and diagnostic mammography, 330 patient-cases were selected. The endpoints were the mean ROC AUC for the reader per breast (breast level), ROC AUC per patient (subject level), noncancer recall rates, sensitivity, and specificity. RESULTS. Twenty-nine of 31 readers performed better with DBT than FFDM regardless of breast density. There was a statistically significant improvement in readers' mean diagnostic accuracy with DBT. The subject-level AUC increased from 0.765 (standard error [SE], 0.027) for FFDM to 0.835 (SE, 0.027) for DBT (p = 0.002). Breast-level AUC increased from 0.818 (SE, 0.019) for FFDM to 0.861 (SE, 0.019) for DBT (p = 0.011). The noncancer recall rate per patient was reduced by 19% with DBT (p < 0.001). Masses and architectural distortions were detected more with DBT (p < 0.001); calcifications trended lower (p = 0.136). Accuracy for detection of invasive cancers was significantly greater with DBT (p < 0.001). CONCLUSION. Reader performance in breast cancer detection is significantly higher with wide-angle two-view DBT independent of FFDM, verifying the robustness of DBT as a sole view. However, results of perception studies in the vision sciences support the inclusion of an overview image.

Gamma Imaging-Guided Minimally Invasive Breast Biopsy: Initial Clinical Experience.

OBJECTIVE: The purpose of this study was to evaluate our initial experience with gamma imaging-guided vacuum-assisted breast biopsy in women with abnormal findings. MATERIALS AND METHODS: A retrospective review of patients undergoing breast-specific gamma imaging (BSGI), also known as molecular breast imaging (MBI), between April 2011 and October 2015 found 117 nonpalpable mammographically and sonographically occult lesions for which gamma imaging-guided biopsies were recommended. Biopsy was performed with a 9-gauge vacuum-assisted device with subsequent placement of a titanium biopsy site marker. Medical records and pathologic findings were evaluated. RESULTS: Of the 117 biopsies recommended, 104 were successful and 13 were canceled. Of the 104 performed biopsies, 32 (30.8%) had abnormal pathologic findings. Of those 32 biopsies, nine (28.1%) found invasive cancers, six (18.8%) found ductal carcinoma in situ (DCIS), and 17 (53.1%) found high-risk lesions. Of the 17 high-risk lesions, there were three (17.6%) lobular carcinomas in situ, five (29.4%) atypical ductal hyperplasias, two (11.8%) atypical lobular hyperplasias, one (5.9%) flat epithelial atypia, and six (35.3%) papillomas. Two cases of atypical ductal hyperplasia were upgraded to DCIS at surgery. The overall cancer detection rate for gamma imaging-guided biopsy was 16.3%. In this study, gamma imaging-guided biopsy had a positive predictive value of total successful biopsies of 16.3% for cancer and 30.8% for cancer and high-risk lesions. CONCLUSION: Gamma imaging-guided biopsy is a viable approach to sampling BSGI-MBI-detected lesions without sonographic or mammographic correlate. Our results compare favorably to those reported for MRI-guided biopsy.

Comparative Diagnostic Utility of Low-Dose Breast-Specific Gamma Imaging to Current Clinical Standard.

To retrospectively compare low-dose (7-10 mCi) to high-dose (15-30 mCi) breast-specific gamma imaging (BSGI) in the detection of breast cancer. A retrospective review of 223 consecutive women who underwent BSGI exam between February 2011 and August 2013 with subsequent pathologic analysis was performed. Women were divided into low-dose and high-dose groups. The results of BSGI and pathology were compared, and the sensitivity, positive predictive value (PPV), and negative predictive value (NPV) were determined. A subgroup analysis was performed to evaluate specificity using benign follow-up imaging to establish true-negative results. There were 223 women who met inclusion criteria with 109 patients with 153 lesions in the low-dose group and 114 patients with 145 lesions in the high-dose group. Pathologic correlation demonstrates sensitivities of 97.6% (95% CI = 90.9-99.6%) and 94.6% (95% CI = 84.2-98.6%; p = 0.093), PPVs of 62.1% (95% CI = 53.2-70.3%) and 50.5% (95% CI = 40.6-60.3%, p = 0.089), and NPVs of 90.5% (95% CI = 68.2-98.3%) and 92.5% (95% CI = 78.5-98.0%, p = 0.781) in the low-dose and high-dose groups, respectively. Subgroup analysis included 72 patients with 98 lesions in the low-dose group and 116 patients with 132 lesions in the high-dose group, with a specificity of 53.7% (95% CI = 39.7-67.1%) and 66.3% (95% CI = 56.2-75.2%%, p = 0.143), respectively. Low-dose BSGI demonstrated high sensitivity and NPV in the detection of breast cancer comparable to the current standard dose BSGI, with moderate specificity and PPV in a limited subgroup analysis, which was associated with a substantial number of false-positives.

Assessing improvement in detection of breast cancer with three-dimensional automated breast US in women with dense breast tissue: the SomoInsight Study.

PURPOSE: To determine improvement in breast cancer detection by using supplemental three-dimensional (3D) automated breast (AB) ultrasonography (US) with screening mammography versus screening mammography alone in asymptomatic women with dense breasts. MATERIALS AND METHODS: Institutional review board approval and written informed consent were obtained for this HIPAA-compliant study. The SomoInsight Study was an observational, multicenter study conducted between 2009 and 2011. A total of 15 318 women (mean age, 53.3 years ± 10 [standard deviation]; range, 25-94 years) presenting for screening mammography alone with heterogeneously (50%-75%) or extremely (>75%) dense breasts were included, regardless of further risk characterization, and were followed up for 1 year. Participants underwent screening mammography alone followed by an AB US examination; results were interpreted sequentially. McNemar test was used to assess differences in cancer detection. RESULTS: Breast cancer was diagnosed at screening in 112 women: 82 with screening mammography and an additional 30 with AB US. Addition of AB US to screening mammography yielded an additional 1.9 detected cancers per 1000 women screened (95% confidence interval [CI]: 1.2, 2.7; P < .001). Of cancers detected with screening mammography, 62.2% (51 of 82) were invasive versus 93.3% (28 of 30) of additional cancers detected with AB US (P = .001). Of the 82 cancers detected with either screening mammography alone or the combined read, 17 were detected with screening mammography alone. Of these, 64.7% (11 of 17) were ductal carcinoma in situ versus 6.7% (two of 30) of cancers detected with AB US alone. Sensitivity for the combined read increased by 26.7% (95% CI: 18.3%, 35.1%); the increase in the recall rate per 1000 women screened was 284.9 (95% CI: 278.0, 292.2; P < .001). CONCLUSION: Addition of AB US to screening mammography in a generalizable cohort of women with dense breasts increased the cancer detection yield of clinically important cancers, but it also increased the number of false-positive results.

Screening breast ultrasound: past, present, and future.

OBJECTIVE. This article discusses breast ultrasound for the detection of breast cancer in the screening environment, as well as strategies for integrating screening breast ultrasound, including automated breast ultrasound. CONCLUSION. Breast density is an increasingly pertinent issue in breast cancer diagnosis. Breast density results in a decrease in the sensitivity of mammography for cancer detection, with a significant increase in the risk of breast cancer. Ultrasound detects additional cancers.

miR-638 mediated regulation of BRCA1 affects DNA repair and sensitivity to UV and cisplatin in triple-negative breast cancer.

INTRODUCTION: Triple-negative breast cancer (TNBC) represents 15 to 20% of all types of breast cancer; however, it accounts for a large number of metastatic cases and deaths, and there is still no effective treatment. The deregulation of microRNAs (miRNAs) in breast cancer has been widely reported. We previously identified that miR-638 was one of the most deregulated miRNAs in breast cancer progression. Bioinformatics analysis revealed that miR-638 directly targets BRCA1. The aim of this study was to investigate the role of miR-638 in breast cancer prognosis and treatment. METHODS: Formalin-fixed, paraffin-embedded (FFPE) breast cancer samples were microdissected into normal epithelial and invasive ductal carcinoma (IDC) cells, and total RNA was isolated. Several breast cancer cell lines were used for the functional analysis. miR-638 target genes were identified by TARGETSCAN-VERT 6.2 and miRanda. The expression of miR-638 and its target genes was analyzed by real-time qRT-PCR and Western blotting. Dual-luciferase reporter assay was employed to confirm the specificity of miR-638 target genes. The biological function of miR-638 was analyzed by MTT chemosensitivity, matrigel invasion and host cell reactivation assays. RESULTS: The expression of miR-638 was decreased in IDC tissue samples compared to their adjacent normal controls. The decreased miR-638 expression was more prevalent in non-TNBC compared with TNBC cases. miR-638 expression was significantly downregulated in breast cancer cell lines compared to the immortalized MCF-10A epithelial cells. BRCA1 was predicted as one of the direct targets of miR-638, which was subsequently confirmed by dual-luciferase reporter assay. Forced expression of miR-638 resulted in a significantly reduced proliferation rate as well as decreased invasive ability in TNBC cells. Furthermore, miR-638 overexpression increased sensitivity to DNA-damaging agents, ultraviolet (UV) and cisplatin, but not to 5-fluorouracil (5-FU) and epirubicin exposure in TNBC cells. Host cell reactivation assays showed that miR-638 reduced DNA repair capability in post UV/cisplatin-exposed TNBC cells. The reduced proliferation, invasive ability, and DNA repair capabilities are associated with downregulated BRCA1 expression. CONCLUSIONS: Our findings suggest that miR-638 plays an important role in TNBC progression via BRCA1 deregulation. Therefore, miR-638 might serve as a potential prognostic biomarker and therapeutic target for breast cancer.

Breast-specific gamma imaging for the detection of breast cancer in dense versus nondense breasts.

OBJECTIVE: The purpose of this study was to evaluate the sensitivity of breast-specific gamma imaging (BSGI) for the detection of breast cancer in dense versus nondense breasts. MATERIALS AND METHODS: This was a retrospective study of 341 women with biopsy-proven breast cancer diagnosed from January 2004 to August 2009 who underwent BSGI before surgical excision. Patients with predominantly fatty replaced (BI-RADS density 1) or scattered fibroglandular tissue (BI-RADS density 2) breasts were classified as nondense, and those with heterogeneously dense (BI-RADS density 3) or extremely dense tissue (BIRADS density 4) were classified as dense. BSGI examinations exhibiting focal increased radiotracer uptake in the area of biopsy-proven cancer were classified as positive according to BSGI reports in the medical record. The sensitivity of BSGI was calculated using Microsoft Excel 2003. Between-group differences were evaluated statistically using the Student t test for continuous variables and the chi-square test for categoric variables, with p < 0.05 considered statistically significant. RESULTS: The overall sensitivity of BSGI for breast cancer detection was 95.4%. Positive BSGI examinations were present in 136 of 142 nondense breast cancers and 195 of 205 dense breast cancers, for sensitivities of 95.8% and 95.1%, respectively. There was no significant difference in BSGI breast cancer detection and parenchymal breast density (p = 0.459). CONCLUSION: BSGI has high sensitivities for the detection of breast cancer in women with dense and nondense breasts and is an effective adjunct imaging modality in women with both dense and nondense breasts.

Effectiveness of Community Education for Breast Cancer Screening.

OBJECTIVE: Screening based on individual risk factors results in detection of earlier, more curable breast cancer. There is expectation that improved public education about the importance of personalized screening will result in earlier diagnoses and reduced breast cancer mortality. The purpose of this study is to evaluate the effectiveness of community education on patient perceptions about risk-based screening. METHODS: This study is Health Insurance Portability and Accountability Act-compliant and institutional review board exempt. A standardized curriculum was used by radiologists and experts to conduct nine 1-hour patient education sessions between October 2018 and January 2019 about breast cancer risk factors and screening options. Patient participants completed voluntary, anonymous pre-event and post event surveys to determine if the presented educational program led to attitude changes. Survey results were summarized using statistical analysis including mean, median, range, and percentage of participants responding and comparison of pre- and post event fear and anxiety. RESULTS: Of 336 education session participants, 59.5% (200/336) completed the pre-event and 44.3% (149/336) completed the post event surveys, Respondents reported decreased anxiety and fear regarding breast cancer screening following educational sessions, with 36.1% (64/178) reporting anxiety pre-event compared to 23.3% (31/133) post event, although the difference was not statistically significant (P = .96). Additionally, 64.7% (55/85) of participants stated they were more likely to schedule breast cancer screening based on individual risk factors, and 98.0% (145/148) of participants reported increased knowledge on post event surveys. CONCLUSION: This study demonstrates the importance and effectiveness of community-based educational programs in increasing knowledge of risk-based screening and potentially reducing anxiety related to screening.

Breast-specific gamma imaging influences surgical management in patients with breast cancer.

Breast-specific gamma imaging (BSGI) is a physiologic breast imaging modality that provides more sensitive detection of breast lesions than mammography or ultrasound, and appears to have greater specificity than breast MRI. The purpose of this study was to evaluate how often BSGI changed surgical management in patients with breast cancer. Charts were reviewed from 218 consecutive eligible patients who had preoperative evaluation with BSGI or MRI before surgery for breast cancer from January 2008 to May 2010. Patients who were initially considered eligible for breast-conserving therapy (BCT) were evaluated to determine how many ultimately had mastectomies. Patients who underwent mastectomy because of personal choice or ineligibility for BCT were excluded. Management was changed to mastectomy in 11.9% of those who had BSGI and 28.9% of those who had MRI. Review of pathology demonstrated that all patients who underwent mastectomies were not candidates for breast conservation. 15.4% of patients who underwent BCT based on BSGI findings required a single re-excision due to positive surgical margins. 14.4% required mastectomy. In the MRI group, 18.8% required a single re-excision, and 6.3% required mastectomy. Evaluation with BSGI changed management to mastectomy in a substantial proportion of patients believed to be eligible for BCT following standard imaging. BSGI is effective in evaluation of extent of disease in patients with breast cancer, and is comparable to MRI in terms of its influence on surgical management.

Body composition and chemotherapy toxicity among women treated for breast cancer: a systematic review.

PURPOSE: Toxicity is a significant problem among women receiving systemic chemotherapy for breast cancer, with up to 60% experiencing hematologic and 14% experiencing non-hematologic toxicity. Chemotherapy is dosed using body surface area, which does not account for heterogeneity in lean body mass (LBM) and adipose tissue (AT). This systematic review, registered with the PROSPERO International Prospective Register of Systematic Reviews (#CRD42021279874), evaluates associations between body composition and chemotherapy-related toxicity during breast cancer treatment. METHODS: Scientific literature databases (PubMed, Scopus, CINAHL, and CENTRAL) were systematically searched in November 2021 for studies evaluating associations between body composition (assessed using computed tomography or dual x-ray absorptiometry) and chemotherapy-related toxicity among women receiving breast cancer treatment. Eligibility was not limited by year or country of publication. Article screening and data abstraction was conducted using the Covidence Systematic Review Management System. Predetermined criteria were used to evaluate rigor of participant recruitment, representativeness of the population, and use of validated measures of body composition and toxicity. RESULTS: An inverse association between LBM and toxicity was reported in seven of the eight included studies, although definitions of low LBM differed across studies. Three studies evaluated the association between AT and chemotherapy toxicity with inconsistent findings. Heterogeneity in body composition measures/definitions and treatment regimens precluded the ability to perform meta-analyses. CONCLUSION: Low LBM appears to be a risk factor for chemotherapy toxicity, but the role of AT is unclear. IMPLICATIONS FOR CANCER SURVIVORS: Further research that accounts for guideline concordance in chemotherapy prescriptions and the use of supportive care medications is needed.

Virtual Interviews for Breast Imaging Fellowship During the COVID-19 Pandemic: Perspectives of Program Directors and Applicants.

OBJECTIVE: To compare in-person and virtual breast fellowship interview experiences from the perspective of fellowship program directors (PDs) and applicants. METHODS: Three separate voluntary, anonymous, e-mail delivered surveys were developed for PDs, in-person interview applicants in 2019-2020, and virtual interview applicants in 2020-2021. PD and applicant survey responses regarding the two interview cycles were compared. RESULTS: The response rate was 56% (53/95) for PDs, 19% (23/123) for in-person applicants, and 38% (49/129) for virtual applicants. PDs reported significantly lower cost for virtual compared to in-person interviews (P < 0.001). They reported no significant difference in number of applications received, number of applicants interviewed, applicant pool geographic regions, number of interview days offered, or format of interviews. Most PDs (31/53, 58%) felt the virtual format still allowed them to get to know the applicants well. Cost was significantly higher for in-person compared to virtual applicants (P < 0.001). More in-person applicants (11/23, 48%) listed cost as a barrier compared to virtual applicants (7/49, 14%) (P = 0.002). Virtual and in-person applicants reported a similar number of program applications, but virtual applicants completed more interviews (P = 0.012). Both groups preferred scheduled time to speak with the current fellows and a one-on-one interview format with two to four faculty members. Most applicants (36/49, 73%) felt the virtual format still allowed them to get to know each program well. CONCLUSION: Virtual interviews provide a reasonable alternative to in-person interviews for breast imaging fellowship applicants, with decreased cost being the main advantage.

Full-field digital mammographic interpretation with prior analog versus prior digitized analog mammography: time for interpretation.

OBJECTIVE: The purpose of our study was to quantitatively compare the time for interpretation of screening full-field digital mammography (FFDM) images using prior analog film mammograms for comparison versus digitized prior analog mammograms. MATERIALS AND METHODS: Images from 100 FFDM studies were interpreted by four radiologists. All FFDM images had comparison analog mammograms obtained a minimum of 1 year earlier that were digitized using a 43-µm film digitizer. Initially, the FFDM images were interpreted using the digitized prior mammogram on two, 5-megapixel monitors and PACS. All available PACS tools could be used. Four weeks later, the same 100 screening FFDMs were interpreted using the original analog mammograms on an alternator at 90° to the monitors used to interpret the screening FFDMs. The interpretation times were recorded and compared. The results were compared and evaluated for statistical significance using statistical software, with statistical significance set at p < 0.05. RESULTS: For each radiologist, the mean reading time for FFDM with digitized priors was significantly shorter in length in comparison with the mean reading time calculated for interpreting FFDM using analog film priors. The differences in times recorded between digitized analog versus analog ranged from 11.31 to 74.18 seconds. The reading times for the four readers ranged from 17.32 to 185.94 seconds, with a mean of 58.56 seconds when using analog film prior mammograms. When using digitized analog prior mammograms, the reading times for the four readers ranged from 11.32 to 109.11 seconds with a mean of 39.76 seconds. The average difference in reading time was calculated to be 18.80 seconds, showing that there is a 32% increase in interpretation speed when using a digitized prior analog for comparison studies as opposed to an analog prior. CONCLUSION: There is a statistically significant 32.1% average improvement in interpretation time when FFDM screening mammograms use digitized analog comparison mammograms than if FFDM is interpreted with the original analog film mammograms. This should allow more FFDMs to be interpreted in the same amount of time if digitized prior analog mammograms are used.

Current and Future Directions of Breast MRI.

Magnetic resonance imaging (MRI) is the most sensitive exam for detecting breast cancer. The American College of Radiology recommends women with 20% or greater lifetime risk of developing breast cancer be screened annually with MRI. However, other high-risk populations would also benefit. Hartmann et al. reported women with atypical hyperplasia have nearly a 30% incidence of breast cancer at 25-year follow-up. Women with dense breast tissue have up to a 4-fold increased risk of breast cancer when compared to average-risk women; their cancers are more likely to be mammographically occult. Because multiple cohorts of women are at high risk for developing breast cancer, there has been a movement to develop an abbreviated MRI (abMRI) protocol to expand the availability of MRI screening. Studies on abMRI effectiveness have been promising, with Weinstein et al. demonstrating a cancer detection rate of 27.4/1000 in women with dense breasts after a negative digital breast tomosynthesis. Breast MRI is also used to evaluate the extent of disease as part of preoperative assessment in women with newly diagnosed breast cancer, and to assess a patient's response to neoadjuvant chemotherapy. This paper aims to explore the current uses of MRI and propose future indications and directions.

The American College of Radiology/Society of Breast Imaging Updated Fellowship Training Curriculum for Breast Imaging.

Since the publication of the most recent breast imaging resident and fellowship curriculum in 2013, there have been widespread changes to the field of breast imaging. Screen-film mammography has been nearly completely replaced, and there has been widespread adoption of breast MRI and digital breast tomosynthesis. Fellowship training programs are increasingly one year in length, which accommodates the rapidly evolving subspecialized field of breast imaging. Recent surveys have identified deficits in nonclinical training related to patient communication and practice audits. This updated fellowship curriculum focuses on four discrete skill sets: clinical, noninterpretive, collaborative, and scholarly. Updates to the clinical curriculum include familiarity with new and emerging imaging technologies and biopsy techniques, as well as a more comprehensive understanding of breast pathology and appropriate follow-up and/or treatment recommendations. There is an increased focus on noninterpretive skills related to the practice audit and quality control. A formal communication curriculum tailored toward discussions with patients is highly recommended. The collaborative value of multidisciplinary care and the benefits of mentorship are emphasized. Finally, scholarly activities including both the opportunity for teaching and research, as well as dedicated lectures and journal clubs, will establish a platform for lifelong learning. This updated curriculum, which has been approved by the Executive Committee of the American College of Radiology and the Society of Breast Imaging Board of Directors, is designed to develop well-rounded fellowship graduates who are positioned to be breast imaging leaders within their future practices.